A panel convened to develop an evidence-based set of guidelines for the recognition and treatment of eye injuries and illnesses that may occur in the wilderness. These guidelines are meant to serve as a tool to help wilderness providers accurately identify and subsequently treat or evacuate for a variety of ophthalmologic complaints. Recommendations are graded based on the quality of their supporting evidence and the balance between risks and benefits according to criteria developed by the American College of Chest Physicians.

Food insecurity is prevalent, affecting 1·2 billion people globally in 2021. However, the effects of food insecurity are unequally distributed across populations and climate-related shocks threaten to exacerbate food insecurity and associated health consequences. The mechanisms underlying this exacerbation at the household level are largely unknown. We aimed to synthesise the available evidence on the mechanisms connecting extreme climate events to household-level food insecurity and highlight the research gaps that must be addressed to inform better food security and health policy. For this systematic review, a comprehensive literature search was done by a medical librarian in February, 2021 for articles about food security and climate-related shocks. Relevant publications were identified by searching the following databases with a combination of standardised index terms and keywords: MEDLINE, Embase, CINAHL, GreenFILE, Environment Complete, Web of Science Core Collection, and Global Health. Searches were limited to human studies published in English. Included studies measured food security outcomes using indicators developed by the UN Food and Agricultural Organization (ie, consumption patterns, livelihood change, malnutrition, and mortality) and explained the mechanism behind the household-level or population-level food insecurity. Purely theoretical, modelling, and review studies were excluded. Quality assessment was conducted using the appropriate Joanna Briggs Institute Critical Appraisal Tool. Data were analysed using thematic analysis of the categories of mechanism (interpreted using internationally accepted frameworks), risk and resilience factors, and author policy recommendations. We found a paucity of data with only 18 studies meeting criteria for inclusion out of 337 studies identified for full-text review. All the studies that were included in our analysis showed worse food security outcomes after climate-related shocks. Food availability was the most common mechanism cited (17 studies), although most studies addressed at least one additional mechanism (15 studies). Studies were of mixed methodologies with nuanced discussions of risk and resilience factors, and of policy recommendations. This systematic review shows that there is an incomplete assessment of food security at the household and community level after climate-related shocks in the literature and finds that food availability is the primary mechanism studied. The low number of studies on this topic limits subgroup analysis and generalisability; however, the good quality of the studies allows for important policy recommendations around improving resilience to climate shocks and suggestions for future research including the need for a more granular understanding of mechanisms and feasible adaptation solutions.

There has been abundant evidence showing the health benefits of a plant-based diet, yet many physicians do not stress the importance these diets as an aspect of chronic disease prevention and treatment. Pediatricians have an important role in dietary education of children, and there is scarce data focused specifically on pediatricians' knowledge regarding plant-based nutrition. Our study addresses this gap by assessing pediatrician's general nutritional knowledge and attitudes regarding plant-based diets. A cross-sectional study was done using a previously implemented questionnaire that was distributed among a sample of pediatricians in the United States. Survey items were scored as a percentage of correct answers based on nutrition knowledge and attitudes toward plant-based diets, and then analyzed and compared among participants. Of 112 respondents surveyed, 86 (76.8%) were general pediatricians and 71 (63.4%) were following a vegetarian or plant-based diet. 57 (50.9%) of the participants had been in medical practice for more than 10 years. 92 (82.1%) of participants received ≤ 10 hours nutrition education in medical school, and 76 (67.9%) of participants had ≤ 10 hours of nutrition-specific continuing medical education since residency training. The mean medical knowledge score was found to be 57.1% ± 20.1%, and participants who followed a whole-foods plant-based diet had significantly higher scores than those who did not follow any specific diet (70.5% ± 13.5 vs. 46.5% ± 20.0) (p < 0.001). The mean attitude score was 49.2% ± 27.6, with participants who had at least one child having significantly higher attitude scores than those without children (53.7% ± 28.1 vs. 41.2% ± 24.9) (p = 0.028). There was a strong positive correlation between participants' medical knowledge and their attitude score (p < 0.001). Pediatricians are exposed to very little nutrition education hours during medical school and in their continued education training. A significant portion of pediatricians in our survey had low average medical knowledge base in vegetarian nutrition and did not hold positive attitudes concerning plant-based diets. Increasing education hours for pediatricians regarding plant-based diets may help them better counsel their patients on their dietary decisions. Physicians Association for Nutrition.

This supplement of Wilderness & Environmental Medicine is a special issue comprising Wilderness Medical Society (WMS) clinical practice guidelines (CPGs). This edition contains both newly developed CPGs and updates to our previously published CPG series. Our goal is to provide the most up-to-date and relevant clinical information to frontline providers in wilderness or austere environments. All recommendations are graded based upon the clinical strength of available evidence as outlined by the American College of Chest Physicians (ACCP) (Table 1).1Guyatt G. Gutterman D. Baumann M. Addrizzo-Harris D. Hylek E.M. Phillips B. et al.Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force.Chest. 2006; 129: 174-181Abstract Full Text Full Text PDF PubMed Scopus (1006) Google ScholarTable 1American College of Chest Physicians classification scheme for grading evidence and recommendations in clinical guidelinesSource: Guyatt et al.1Guyatt G. Gutterman D. Baumann M. Addrizzo-Harris D. Hylek E.M. Phillips B. et al.Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force.Chest. 2006; 129: 174-181Abstract Full Text Full Text PDF PubMed Scopus (1006) Google ScholarGradeDescriptionBenefits vs risks and burdensMethodologic quality of supporting evidence1AStrong recommendation, high-quality evidenceBenefits clearly outweigh risks and burdens or vice versaRCTs without important limitations or overwhelming evidence from observational studies1BStrong recommendation, moderate-quality evidenceBenefits clearly outweigh risks and burdens or vice versaRCTs with important limitations or exceptionally strong evidence from observational studies1CStrong recommendation, low-quality or very low-quality evidenceBenefits clearly outweigh risks and burdens or vice versaObservational studies or case series2AWeak recommendation, high-quality evidenceBenefits closely balanced with risks and burdensRCTs without important limitations or overwhelming evidence from observational studies2BWeak recommendation, moderate-quality evidenceBenefits closely balanced with risks and burdensRCTs with important limitations or exceptionally strong evidence from observational studies2CWeak recommendation, low-quality or very low-quality evidenceUncertainty in the estimates of benefits, risks, and burden; benefits, risk, and burden may be closely balancedObservational studies or case seriesRCT, randomized controlled trial. Open table in a new tab RCT, randomized controlled trial. CPGs are increasingly necessary to help clinicians navigate and synthesize the expanding volume of available medical literature. A unified and reliable approach to the development of CPGs has not yet been universally adopted, in large part owing to variability in the quality of evidence available. Well-designed and adequately powered randomized clinical trials (RCTs) lend themselves well to situations where common ailments (eg, diabetes mellitus) can be treated dichotomously (medication vs placebo). High-quality evidence is far more difficult to obtain in procedural specialties (which are subject to large variations in technique, myriad related biases, and difficulty blinding) or for rare conditions. Certainly, the latter is an inherent challenge in austere medicine. The illnesses and injuries we treat are not only rare, they also occur in challenging and remote environments. For both practical and ethical considerations, it is difficult to design and execute RCTs for the treatment of conditions such as high altitude cerebral edema, venomous reptile bites, or lightning strikes. Even more common conditions such as frostbite, acute mountain sickness, hypo- and hyperthermia, and submersion injuries are relatively infrequently seen and unpredictable in circumstance. The Institute of Medicine (IOM) published guidelines for the development of a standardized approach for objective, scientifically valid, and consistent approaches to developing CPGs in 2008.2Graham R. Mancher M. Wolman D.M. Greenfield S. Steinberg E. Institute of Medicine of the National Academies. Clinical Practice Guidelines We Can Trust. National Academies Press, Washington, DC2011Crossref Google Scholar In spite of this, an independent review of 130 CPGs published in 2012 revealed that less than half met more than 50% of the IOM standards.3Kung J. Miller R.R. Mackowiak P.A. Failure of clinical practice guidelines to meet the Institute of Medicine standards: two decades of little, if any, progress.Arch Intern Med. 2012; 172: 1628-1633Crossref PubMed Scopus (219) Google Scholar The following represents the efforts of the WMS to develop a sound CPG process, based on the principles outlined by the IOM. Transparency. The WMS will clearly publicize the process by which CPGs are developed. Our CPG committee meetings are open to the WMS membership, and our process will be delineated in editorials such as this communication. Guideline development and group composition. Guideline panel membership is a main determinant of the trustworthiness of guidelines.4Shaneyfelt T. In guidelines we cannot trust.Arch Intern Med. 2012; 172: 1633-1644Crossref PubMed Scopus (50) Google Scholar The WMS is committed to ensuring that each CPG is developed by a working group representative of the best experts in the field and multidisciplinary in scope. The proposed authorship panel for each WMS CPG is approved by the WMS clinical practice guidelines committee. Additional input from the journal's editorial staff and the WMS board of directors is sought to ensure the final panel represents the best expertise in the field. There is no requirement for panel members to be WMS members. Conflicts of interest. The WMS CPG development protocol requires complete disclosure or real or potential conflicts of interest for all panel members. Panel members with significant conflict of interest are removed from the process. Use of best evidence available. The WMS is committed to ensuring that each CPG panel, as a whole, possesses a sufficient level of expertise to search, identify, critique, and grade the available evidence to ensure the most inclusive search and identification of the highest level of evidence. The inclusion of supplementary data tables with each CPG attempts to provide further detail regarding the quality of evidence on which each recommendation is based. The periodic revision and updating of each CPG ensures that current literature and thinking are included. The committee believes the classification scheme developed by the ACCP1Guyatt G. Gutterman D. Baumann M. Addrizzo-Harris D. Hylek E.M. Phillips B. et al.Grading strength of recommendations and quality of evidence in clinical guidelines: report from an American College of Chest Physicians task force.Chest. 2006; 129: 174-181Abstract Full Text Full Text PDF PubMed Scopus (1006) Google Scholar offers the best fit for WMS CPGs. Much of the evidence in wilderness medicine is of low quality or small numbers, and our recommendations are often classified as strong or weak based more on the benefit vs risk of an intervention than on the quality of evidence supporting it. The ACCP guidelines offer the ability to assign grades with a description of how the strength of the recommendation is influenced by both evidence and the risk/benefit ratio. Other systems are less clear in this regard, or seemingly equate the strength of the recommendation disproportionately to the strength of evidence. Although a rigid approach may be appropriate in clinical areas where high levels of evidence exist, we believe it is less useful when the preponderance of evidence is of lower quality. Evidence quality and recommendation strength. For each recommendation, CPGs should provide sound reasoning, meaningful discussion of benefits and risks, and a description of the relative strength of the evidence and the role of subjective judgments. Differences of opinion among panel members are discussed. Articulating recommendations. CPGs should clearly articulate the action recommended and the circumstances around which action should be taken. External review. All WMS CPG manuscripts are submitted to Wilderness & Environmental Medicine and are subject to the same independent, rigorous, single-blinded peer review process as any other submitted manuscript. Updating. The WMS is committed to timely updating of all CPGs. Authors are expected to keep articles as evidence based and current as possible; thus, some CPGs with new or changing data may be updated more frequently than others. Feedback. Any feedback on our CPGs can be directed to the WMS CPG committee. Contact information can be found on the WMS website. We will use this feedback to evaluate, innovate, and improve on future CPGs. We believe that our process represents the best course for the Society to produce timely, relevant, and trustworthy CPGs. Previously published guidelines have been some of the most highly cited articles in Wilderness & Environmental Medicine. It is our foremost goal to continue the tradition of bringing forward the best available data to the wilderness medical provider.

Introduction: Emergency medicine (EM) throughout Africa exists in various stages of development. The number and types of scientific EM literature can serve as a proxy indicator of EM regional development and activity. The goal of this scoping review is a preliminary assessment of potential size and scope of available African EM literature published over 15 years. Methods: We searched five indexed international databases as well as non-indexed grey literature from 19992014 using key search terms including "Africa", "emergency medicine", "emergency medical services", and "disaster." Two trained physician reviewers independently assessed whether each article met one or more of five inclusion criteria, and discordant results were adjudicated by a senior reviewer. Articles were categorised by subject and country of origin. Publication number per country was normalised by 1,000,000 population. Results: Of 6091 identified articles, 633 (10.4%) were included. African publications increased 10-fold from 1999 to 2013 (9 to 94 articles, respectively). Western Africa had the highest number (212, 33.5%) per region. South Africa had the largest number of articles per country (171, 27.0%) followed by Nigeria, Kenya, and Ghana. 537 (84.8%) articles pertained to facility-based EM, 188 (29.7%) to out-of-hospital emergency medicine, and 109 (17.2%) to disaster medicine. Predominant content areas were epidemiology (374, 59.1%), EM systems (321, 50.7%) and clinical care (262, 41.4%). The most common study design was observational (479, 75.7%), with only 28 (4.4%) interventional studies. All-comers (382, 59.9%) and children (91, 14.1%) were the most commonly studied patient populations. Undifferentiated (313, 49.4%) and traumatic (180, 28.4%) complaints were most common. Conclusion: Our review revealed a considerable increase in the growth of African EM literature from 1999 to 2014. Overwhelmingly, articles were observational, studied all-comers, and focused on undifferentiated complaints. The articles discovered in this scoping review are reflective of the relatively immature and growing state of African EM.

Introduction-In 2014, the Wilderness Medical Society (WMS) published guidelines for the treatment of acute pain in remote settings. We surveyed wilderness medicine providers on self-reported analgesia prescribing practices. Methods-We conducted a prospective, anonymous survey. Respondents were recruited from the WMS annual symposium in 2016. All willing attendees were included. Results-During the symposium, we collected a total of 124 surveys (68% response rate). Respondent age was 42 +/- 12 (24-79) years (mean +/- SD with range), 58% were male, and 69% reported physician-level training. All respondents had medical training of varying levels. Of the physicians reporting a specialty, emergency medicine (59%, n=51), family medicine (13%, n=11), and internal medicine (8%, n=7) were reported most frequently. Eighty-one (65%) respondents indicated they prefer a standardized pain assessment tool, with the 10-point numerical rating scale being the most common (54%, n=67). Most participants reported preferring oral acetaminophen (81%, n=101) or nonsteroidal anti-inflammatory drugs (NSAID) (91%, n=113). Of those preferring NSAID, most reported administering acetaminophen as an adjunct (82%, n=101). Ibuprofen was the most frequently cited NSAID (71%, n=88). Of respondents who preferred opioids, the most frequently preferred opioid was oxycodone (26%, n=32); a lower proportion of respondents reported preferring oral transmucosal fentanyl citrate (9%, n=11). Twenty-five (20%, n=25) respondents preferred ketamine. Conclusions-Wilderness medicine practitioners prefer analgesic agents recommended by the WMS for the treatment of acute pain. Respondents most frequently preferred acetaminophen and NSAIDs.

Background: Drugs of abuse (DOA) are widely used in the United States and are ubiquitous at outdoor music festivals. Attendees at music festivals are at high-risk for novel psychoactive substance (NPS) use, which is becoming more prevalent worldwide. No U.S. studies have employed an qualitative approach to investigate the etiologies of both traditional DOA and NPS use amongst music festival attendees. Objectives: The objective of this study was to improve understanding of the knowledge, attitudes, beliefs, and practices of festival attendees using NPS and DOA. Methods: We conducted semi-structured interviews of 171 attendees during the Sonic Bloom and Arise music festivals in Colorado in 2015 and 2016. Discrete variables were summarized with descriptive statistics. The anonymous, multi-domain interview documented the knowledge, attitudes beliefs, and practices underlying DOA use, which were analyzed with qualitative methods. Results: We enrolled 171 participants that endorsed DOA use at the festivals. Most were experienced DOA users, who perceived minimal risks associated with DOA and NPS use. Nearly all unanimously reported normalization of DOA at music festivals. Participants popularly cited empathogenic, entactogenic, and entheogenic effects of DOA as their primary motivations for use. NPS use was endorsed by 39.8% (n = 68) of respondents, all of whom identified as being experienced DOA users. Conclusions: This population of novel psychoactive substance users is primarily composed of experienced drug users that endorsed use because of low cost, minimal perceived risk, accessibility, and normalization of drug use at music festivals.

Obstacle, adventure and endurance competitions in challenging or remote settings are increasing in popularity. A literature search indicates a dearth of evidence-based research on the organisation of medical care for wilderness competitions. The organisation of medical care for each event is best tailored to specific race components, participant characteristics, geography, risk assessments, legal requirements, and the availability of both local and outside resources. Considering the health risks and logistical complexities inherent in these events, there is a compelling need for guiding principles that bridge the fields of wilderness medicine and sports medicine in providing a framework for the organisation of medical care delivery during wilderness and remote obstacle, adventure and endurance competitions. This narrative review, authored by experts in wilderness and operational medicine, provides such a framework. The primary goal is to assist organisers and medical providers in planning for sporting events in which participants are in situations or locations that exceed the capacity of local emergency medical services resources.

BACKGROUNDHigh-altitude flight simulation familiarizes military trainees with the symptoms of hypoxia to prepare them for emergency situations. Decompression sickness (DCS) can occur as a result of these simulations. In cases when ground-level supplemental oxygen does not resolve symptoms, hyperbaric oxygen (HBO) therapy is indicated. Many military hyperbaric chambers have been closed because of cost reductions, necessitating partnerships with community hospitals to ensure access to treatment.MATERIALS AND METHODSThis article describes the unique arrangement between a community hospital in Colorado and a military training site to treat DCS cases emergently. We gathered cost data from the community hospital to estimate and compare the cost of providing HBO therapy in the hospital versus a standalone chamber similar to the former military hyperbaric chamber.RESULTSSince the closure of the military hyperbaric chamber, the community hospital treated an estimated 50 patients with DCS requiring HBO therapy attributed to high-altitude flight simulation between October 2003 and April 2015. Cost to the institution providing HBO treatment varies widely on the basis of patient volume. Assuming a volume of five treatments, per-treatment cost at a standalone center is $95,380. In contrast, per-treatment cost at the hospital assuming a volume of 1,000 treatments commensurate with the hospital's ability to bill for other services is $698 per treatment.CONCLUSIONThe cost analysis demonstrates that the per-treatment cost of operating a standalone HBO therapy center may be greater than 100 times that of operating a center at a community hospital, suggesting the arrangement is beneficial to the military.

The Wilderness Medical Society convened a panel to review available evidence supporting practices for the prevention and acute management of drowning in out-of-hospital and emergency medical care settings. Literature about definition and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded evidence supporting practices according to the American College of Chest Physicians criteria, then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking.

Involvement with Wilderness & Environmental Medicine in any capacity is a true honor. The previous editor-in-chief, Robert Norris, served in the position for a full 10 years, longer than any editor in the journal’s history. In 2010, when Dr Norris announced that he would step aside, Paul Auerbach, the journal’s first editor-in-chief, selected a new team. This team would include Scott McIntosh as editor-in-chief and Tracy Cushing and Linda Keyes as associate editors. Looking back as our team of 3, we are amazed that anyone could function in this role as a solitary editor. We have great respect for those who have accomplished this feat. Past editors, in order, are Paul Auerbach (1990–1994), Oswald Oelz (1990–2000), William Robinson (1995–2000), and Robert Norris (2000–2010). When Dr Norris started his tenure as editor-in-chief, Wilderness & Environmental Medicine received 38 original manuscript submissions during his first year. The number of submissions has grown steadily since that time. In 2014, under the current administration, we received 228 submissions, reflecting impressive growth. We are proud to have the privilege to be more discriminating in our choices. With growth in submissions, the caliber of published manuscripts has also increased. Wilderness & Environmental Medicine has undergone a number of changes over the past 5 years. We redesigned the cover for the first issue of 2011 to modernize its look and managed the well-received Wilderness Medical Society (WMS) Practice Guideline series that has provided practitioners with evidence-based direction for wilderness medicine topics. Jonna Barry, managing editor since 1999, has been the life and cornerstone of the journal. At the beginning of 2015, she finally took a well-deserved retirement and handed over the position to Alicia Byrne. Alicia comes to us with a background in medical publishing and a lifelong appreciation of the natural world. She tells us she is honored to have the opportunity to work on a journal that covers such an important and fascinating topic. As part of the current evolution of the journal, the WMS brought on Neal Pollock as an additional associate editor in October 2014. He has served as a reviewer for 20 different journals and has been a member of the Wilderness & Environmental Medicine editorial board since 2005. This year will mark another major transition for the journal. Scott McIntosh will step aside to pursue other leadership positions within the WMS and to further develop the Diploma in Mountain Medicine and other mountain medicine pursuits. Martin Hoffman will assume the role of editor-in-chief. He brings a solid track record of scientific publication with years of past experience on numerous editorial boards and has been a regular contributor to Wilderness & Environmental Medicine. But, he tells us, he recognizes that he has not seen it all just yet! Tracy Cushing will also step aside to dedicate time to being associate editor of Auerbach’s Wilderness Medicine, Seventh Edition, and to focus on wilderness medicine fellowship education at the University of Colorado. The monumental task of editing the most respected text in wilderness medicine has been possible only because of the opportunities, experiences, and mentorship Tracy has had as associate editor of Wilderness & Environmental Medicine. Linda Keyes will continue her role as associate editor, pursuing her ongoing goal to increase the quality of wilderness medicine research and publications and extending her more than 10 years of service on the Wilderness & Environmental Medicine editorial board. We thank all of the previous Wilderness & Environmental Medicine editors for their vision and perseverance in this endeavor. We also thank the editorial board, the section editors, and the reviewers for all their support and dedication to the journal and its leadership team. And of course, the authors of every paper that has been submitted to Wilderness & Environmental Medicine are to be congratulated for their work and efforts. You are the core of this journal. Wilderness medicine is truly an amazing field, and Wilderness & Environmental Medicine is the center of the specialty. We encourage all readers to continue to seek, strive, and be curious about the wilderness, the environment, and the world around them. The world will be better because of it.

We surveyed Nepali porters and guides as well as English- and non-English-speaking trekkers on their knowledge of altitude illness and its treatment during trekking expeditions to the Annapurna region of Nepal. From March 15 to April 15, 2014, Nepali porters and visiting trekkers were surveyed regarding their ability to recognize and treat altitude illness in Manang, Nepal (3540 m). Their personal use of medications and home remedies and presence of acute mountain sickness (AMS) symptoms were also assessed. 504 subjects were surveyed, including 108 Nepalis. Overall incidence of AMS symptoms was 16%, 5% among Nepalis, and 21% among trekkers. Subjects recognized that headache (88%) was one of the symptoms of AMS, however many reported not knowing the symptoms of high altitude pulmonary edema (40%) or high altitude cerebral edema (42%). 58% of subjects reported carrying and 16% reported taking acetazolamide, while only 2 (0.4%) respondents took dexamethasone. The majority of subjects reported that they would be able to recognize (67%) and treat (62%) altitude illness. Trekkers reported a higher incidence of AMS symptoms than Nepalis. Although most respondents recognized symptoms of AMS, both Nepalis and trekkers lacked knowledge regarding more serious presentations of altitude illness, thus both groups were overconfident in their ability to recognize and treat altitude illness.

The Arkansas Headwaters Recreation Area (AHRA) is one of the most popular Colorado locations for whitewater rafting. Any fatalities that occur during commercial rafting trips in this area are reported to the Colorado Parks and Wildlife service. Whitewater rafting is an activity with inherent risks associated, but certain factors may increase these risks.

Participation in wilderness and adventure sports is on the rise, and as such, practitioners will see more athletes seeking clearance to participate in these events. The purpose of this article is to describe specific medical conditions that may worsen or present challenges to the athlete in a wilderness environment.

History tells us that Albert Calmette happened upon snake antivenom by necessity rather than academic curiosity. A protégée of Louis Pasteur, Dr Calmette was stationed in French Indochina (now Vietnam) in the late 1800s where he had just founded the Pasteur Institute at Saigon in 1891. During his stay in Asia, he studied snake and bee venom, plant poisons, and curare. He documented a harrowing situation:“A village in the environs of Bac-Lieu (Cochin-China) was invaded, in October 1891, at the time of the great rains, by a swarm of venomous snakes belonging to the species Naja tripudians or Cobra capel. These animals, driven into the native huts by the flood, bit 40 individuals of whom four, as reported to us, died almost immediately. An Annamite [a native of the Annamite mountain range] was able to capture and enclose in a barrel, 19 of these cobras and the administrator of the region, M. Séville kindly sent them to the laboratory. 14 arrived alive. We killed 11 of them immediately to remove their venom glands.1Calmette A. Etude éxperimentale du venin de Naja tripudians ou Cobra capel.Annales de l’Institut Pasteur. 1892; 6: 160-183Google Scholar (See Figure.) Calmette injected the venom into horses and collected the Immunoglobulin G antibodies to produce the first antivenom (known as Calmette’s serum). Since then, the process of developing snake antivenom has been refined. In modern formulas, usually just the Fab fragments are used. That retains the efficacy of binding to the venom but reduces hypersensitivity reactions. This issue of Wilderness & Environmental Medicine highlights how we continue to learn about snake envenomation and treatment. In the article by Monzavi et al, we see that protocols for administering snake antivenom continue to develop and be refined. The article by Witham et al describes a novel phenomenon of rebound coagulopathy many days after snake bite envenomation. Although less critical than systemic reactions, Koh et al describe the skin manifestations of a man who was sprayed with cobra venom. Such cutaneous reactions do not require antivenom, but instead, careful and watchful waiting. In the wilderness, snakes are not the only critters whose bite requires attention. In this issue, we cover several other animals that turn their “fangs” against humans. Borek et al describe the risks of reptile zookeeping in “How not to train your dragon: a case of a Komodo dragon bite.” Our Letters to the Editor discuss whether shark bites and attacks on humans are provoked or not provoked. In the article by Bosmia et al, the authors describe how the Sateré-Mawé Indians in the Brazilian Amazon use the bites of bullet ants as part of initiation into adulthood. We are thankful that this practice is not widespread. Finally, if you encounter serious bleeding from a bite or other trauma, the reviews by Drew and Littlejohn et al will help you manage it in the field. Be careful out there!

Defining the field of wilderness medicine can be challenging, particularly for those who do not participate. The founders had a vision of a specialty that incorporates the essentials of practicing medicine in the outdoors without the “luxuries” of a hospital or medical clinic. Rumors abound of the early naming debates—should this group of researchers and practitioners be named the “Wilderness Medical Society,” the “Mountain Medicine Society,” or another, more specific title? Mountain medicine includes high altitude medicine, hypothermia, frostbite, and avalanche injuries, to name a few. Wilderness medicine encompasses mountain medicine, but its scope reaches far beyond. Dive and marine medicine, plant toxinology, animal attacks, and search and rescue all fall within this broad field. Difficult access to patients and environmental extremes are common elements that produce an array of challenges to medical practice. This issue is a tribute to the expansive range of topics that comprise wilderness medicine. Scanning the Table of Contents, one sees articles on familiar topics such as hypothermia, lightning, and climbing injuries. But there are also articles on ultraendurance physiology, an elephant attack, and snake envenomation possibly confused with heat pathology. We also publish an article on the possible toxicologic cause of death of Christopher McCandless, who died after foraging while stranded in Alaska. While research on this topic could easily find a home in a nutrition or toxicology journal, we believe that these specialties would not capture the essence of a man struggling to survive in the outdoors. Our specialty has been defined through 30 years of research and clinical activity. The attention and interest that is being directed towards wilderness medicine in recent years is a testament to the efforts of the founders and developers of the specialty. Each individual that has performed research, helped another in the outdoors, or attended a conference hosted by the Wilderness Medical Society holds a piece of the creation and progression of wilderness medicine. Please continue to contribute, and the specialty will continue to thrive.

Climbing is a popular wilderness sport among a wide variety of professional athletes and amateur enthusiasts, and many styles are performed across many environments. Potential risks confront climbers, including personal health or exacerbation of a chronic condition, in addition to climbing-specific risks or injuries. Although it is not common to perform a preparticipation evaluation (PPE) for climbing, a climber or a guide agency may request such an evaluation before participation. Formats from traditional sports PPEs can be drawn upon, but often do not directly apply. The purpose of this article was to incorporate findings from expert opinion from professional societies in wilderness medicine and in sports medicine, with findings from the literature of both climbing epidemiology and traditional sports PPEs, into a general PPE that would be sufficient for the broad sport of climbing. The emphasis is on low altitude climbing, and an overview of different climbing styles is included. Knowledge of climbing morbidity and mortality, and a standardized approach to the PPE that involves adequate history taking and counseling have the potential for achieving risk reduction and will facilitate further study on the evaluation of the efficacy of PPEs.

Having just returned from the International Society for Mountain Medicine conference in Bolzano, Italy, the Editors are reminded of the international nature of wilderness and mountain medicine. Researchers across the globe are working to understand the needs and improve the care of patients in wilderness and mountain environments. Meetings such as this foster a sense of collaboration and cooperation across oceans and cultures. Learning from the best in the field might mean traveling to the European Alps to study avalanche and crevasse rescue, to Asia to investigate native populations and their unique adaptations to altitude, or to Nepal to collaborate with those who are advancing excellent medical care at remote clinics. Our current Wilderness & Environmental Medicine issue highlights work from the dusty streets of Kathmandu, to the pastured peaks of the Austrian Alps, to the forests of New York State. One of the core topics of Wilderness & Environmental Medicine is dive injuries and the effects of water and hyperbaric pressure on the human body. The study by Lemaitre et al in this issue teaches us about breath-hold, or “free” divers, and their susceptibility to developing bubbles in the blood stream that contribute to decompression sickness. The sport of free diving has gained popularity over the past number of years with dive records well exceeding 100m on a single breath, without the use of sleds or weights to descend or ascend. Along with the increase in the sport’s popularity and participants pushing the limits of depth, fatalities have increased as well. Shallow water blackouts are responsible for the majority of these deaths, as divers have nearly completed their dive when overwhelming hypoxemia causes unconsciousness. William Trubridge, a champion free diver, lost consciousness at 12m below the surface while ascending from a dive in 2006. He survived the incident and still teaches free-diving today, but reportedly has lost his sense of taste, which has never returned. Much is to be learned about free-diving, and Wilderness & Environmental Medicine seeks research and submissions that will help reveal the physiology of these unique sportsmen and to improve their safety, both during competition and recreation. On the other side of the spectrum, high altitude climbers are trying to make themselves hypoxic to prepare for high peaks. Hypoxic tents have been an intriguing option for those attempting to “pre-acclimatize” to high altitudes. They work by enhancing the nitrogen content into ambient air, thereby decreasing the available pressure of oxygen. In this issue, Dehnert et al showed a decrease in acute mountain sickness after sleeping in a hypoxic tent for two weeks. Few other quality studies on the effects of hypoxic tents have been completed to date, even though many high altitude expeditions and coaches of low altitude athletes are recommending that clients sleep in these tents prior to their trip or competition. Some guide services are purporting to decrease the total time of an 8000m peak ascent to under 4 weeks using hypoxic tents for training. This is intriguing and attractive to those who have restricted time in their schedule. However, the expense and sparse evidence of hypoxic tents has limited their universal acceptance. We hope that more research will shed light on their applicability in the future. Whether diving or climbing, cold or hot, high or low, the wilderness and austere environments are what keep us playing in the outdoors as well as attentive to its risks. The field of wilderness medicine stands only to benefit from international collaboration, research, and the sharing of information – including publications such as Wilderness & Environmental Medicine.

You have probably noticed that our latest issues have been slightly "fatter" than previous issues. Submissions to Wilderness & Environmental Medicine have continued to rise, and the quality of submissions has risen as well. Elsevier, our publisher, has graciously agreed to expand our page number from 100 to 125 pages per issue. This will allow our increasing volume of manuscripts to be published in a more timely manner. We thank Elsevier for their partnership and support of our journal and authors.